2018-2019 Extended Care Enrollment Form
Email address *
Student First Name *
Your answer
Student Last Name
Your answer
Student Date of Birth *
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Gender *
Grade *
Homeroom Teacher (not required)
Enrollment Status *
Registration fee $70 for FT and PT students: *
I understand there will be an additional $10 fee for any half day my student attends Extended Care. *
Father's Name *
Your answer
Father's Address if different from student
Your answer
Father's Cell Phone *
Your answer
Father's Work Phone
Your answer
Mother's Name *
Your answer
Mother's Address if different from student
Your answer
Mother's Cell Phone *
Your answer
Mother's Work Phone
Your answer
If parents are divorced, which parent has custody? *
Siblings enrolled in Extended Care:
Your answer
Emergency Contact 1 if parents cannot be reached *
Your answer
Emergency Contact 1 Cell Phone *
Your answer
Emergency Contact 1 Work Phone
Your answer
Can this Emergency Contact 1 pick up your child? *
Emergency Contact 1 relationship to student *
Your answer
Emergency Contact 2 if parents cannot be reached: *
Your answer
Emergency Contact 2 Cell Phone *
Your answer
Emergency Contact 2 Work Phone
Your answer
Can Emergency Contact 2 pick up your child?
Emergency Contact 2 Relationship to Student *
Your answer
Person allowed to pick up student from Extended Care (other than parents & Emergency contacts) - Name, Cell, relationship to student
Your answer
Person allowed to pick up student from Extended Care 2 (other than parents & Emergency Contact) - Name, Cell, relationship to student
Your answer
Health History *
Required
Specify your student's allergies
Your answer
Other Health Concerns
Your answer
Does your student have an inhaler?
Does your student have an Epi-Pen?
Is student restricted from any physical activities?
Your answer
In an Emergency - Physicians Name *
Your answer
In an Emergency - Physicians Phone Number *
Your answer
Physicians Address
Your answer
Preferred Hospital *
Your answer
Authorization for Emergency Medical Treatment: If my student should become ill or injured at SFA Extended Care, I understand that the facility will (1) contact me immediately or (2) contact the person(s) I have designated if I cannot be reached. Should the facility be unable to reach me and/or the person(s) designated, they are authorized to contact my child'd physician and/or medical facility to administer emergency medical treatment necessary to ensure the health and safety of my student. I will accept responsibility of payment for the medical services rendered. *
I acknowledge that I have received the Extended Care Handbook and the Tennessee Department of Education Child Care Requirement Summary. Click on this link to review http://www.sfawolves.org/apps/pages/index.jsp?uREC_ID=661092&type=d&pREC_ID=1112435 *
I understand that Extended Care is a part of St Francis of Assisi School; therefore all rules and regulations set forth in the SFA Parent-Student Handbook must be followed by all students during Extended Care. Click on this link to review the SFA Parent-Student Handbook: http://www.sfawolves.org/apps/pages/index.jsp?uREC_ID=661092&type=d&pREC_ID=1112435 *
I have read and understand the registration fee, weekly fee schedule and the full time (3-5 days a week) and part time status (2 days or less). All fees will be paid through FACTS. http://www.sfawolves.org/apps/pages/index.jsp?uREC_ID=661092&type=d&pREC_ID=1112435 *
I understand my child's status can only change 1x per semester with Director's prior approval. *
I agree to abide by the Payment Policy and I understand the consequences of late payments. *
I understand there are no refunds given and weekly fees will not be rolled over to the next week due to inclement weather or illness. *
I have read and understand the Behavior Policy and "3 Strikes and You Are Out" of Extended Care. I will make sure my student is aware of this policy. *
I have read and understood the policy for cell phones and all other electronic devices. I will make sure my child is aware of this policy. *
I acknowledge the Extended Care Program can at any point institute any course of disciplinary action it deems necessary and consistent with the policies and procedures of St. Francis of Assisi Catholic School. *
Signature of Parent Completing Form *
Your answer
Date completed form *
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A copy of your responses will be emailed to the address you provided.
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